14110052F
tCIUPERTINO
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CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE ^ CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 ^ building cupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION / TI ❑ REVISION/ DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS 2,10111 SteVZ ! / �, g a Q APN N `� _ �? ^ �
"!� JPHONE
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OWNERNAME I-I S "'r �y�I�YA'� }.� D/�
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CITY, STATE, ZIP 5r lh
STREET ADDRESS m S, �tA Vi
FAX
CONTACT NAME
PHONE
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STREET ADDRESS LA [0o � 0
CITY, STATE, ZIP Q -1
FAX
❑ OWNER ❑ OWNER - BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
COI.19ACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LJC #
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COMPANY NAME
E -MAIL
STREET
D , o;-,, e - t i
CITY, 5C1r�I�
ARCHITECT /ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
EMAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
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DESCRIPTION OF WORK pv fib & /e o q ect I 34a�) '71P)
If
EXISTING USE
PROPOSED USE CONSTR.
TYPE
# STORIES
(�
..YY/''
J;r
_b
p
-
USE
TYPE
OCC,
SQ.FT. VALUATION (S)
EXISTG
AREA 1 3 L Q
NEW FLOOR
AREA
DEMO
AREA
TOTAL
NET AREA
��
I�� D��
BATHROOM
KITCHEN
OTHER
'...
REMODELAREA
REMODEL AREA
REMODEL AREA
''......
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: LJ DETACH
I
❑ ATTACH
# DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY ❑YES
BEING ADDED? []NO
ADDITION? []NO
PRE - APPLICATION fOYES IF YES, PROVIDE COPY OF
IS THE BLDG AN C] YES
RECEIVE Y: _ _
TOTAL VALUATION:
PLANNING APPL # NO PLANNING APPROVAL LETTER
EICHLER HOME? `? No
„.
By my signature below, I certify to each ofthe following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to b�construction. ize repr esentatives of Cupertino to enter the ab c- identifed operty for inspection purposes.
Signature o
of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
OVER-THE-COUNTER
BUILDING PLAN REVIEW
_ New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
�EXPRESS
.
permit for new building.
° ❑' PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
'❑ STANDARD
❑ 'PUBLIC WORKS ,
form if any Hazardous Materials are being used as part of this project.
❑
LARGE a`
FIRE DEPT;,°
Copy of Planning Approval Letter or Meeting with Planning prior to
❑
submittal of Building Permit application.
MAJOR
SANITARY SEVI'ERDISTRICT
❑ , ENVIRONAIENTAL HEALTH
B1dgApp_2011.doc revised 06121111
02
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20111 STEVENS CREEK BLVD
CONTRACTOR: DOUBLE ED
PERMIT NO: 14110052,
CONSTRUCTION INC
OWNER'S NAME: TRANS- CONTINENTAL REAL ESTATE INVS
189 BELEVUF AVF,
DATE ISSUED: 11/10/2014
OWNER'S PHONE:
PARTY CITY, CA 94014
PHONE NO: (415) 420 -8145
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL 0
M Q
�
TENANT IMPROVEMENT PREP FOR SUITE 130.
License Class ,� # tr�G�
�i�Lic.
Contractor W6� ' D eVa "/ Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self - insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
Sq. Ft Floor Area:
Valuation: $2000
performance of the work for which this permit is issued.
have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
APN Number: 31623026.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Issued by: ��ia/� /
granting of this permit. Additionally, the applicant understands and will comply
%G,L� Date:
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
1
P!,
RE- ROOFS:
Signature Date ��'��
All roofs shall be inspected prior to any roofing material being installed. if a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER - BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(x) should I store or handle hazardous
1 have and will maintain a Certificate of Consent to self- insure for Worker's
material. Additionally, should 1 use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner rI "r
permit is issued.
or authorized agent: Date:
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, 1 must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
costs, and expenses which may accrue against said City in consequence of the
t understand my plans shall be used as public records,
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CITY OF CUP ERTINO
FEE ESTIMATOR - BUl[l BIND DIVISION
ADDRESS: 20111 Stevens Creek #130 DATE: 1111012014 REVIEWED BY: Sean
APN: BE #: O 'VALUATION: $2,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant improvement
PRIMARY Commercial Building PENTAMATION 1TIPREP
USE: I PERMIT TYPE:
WORK Tenant improvement Prep for suite 130.
SCOPE
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are based on the areliminary information available and are only an estimate. Contact the Deot for addn'l info.
]FEE ITEMS (Tee Resolution 11 -053 Eff.' 7i1/13
FEE
1'hwd, Noll t b,-' 1,
! el. Plan Oyedr
all' P. Pe7nli1 „�.
Piur�rll. P- ::!'�nir ?tie:
TI��c Fr•rr;;it 1''e %�
L-1 I
Q.Q
hrs
- 1��G7t
PME Plan Check:
e(.'. 1i2S17,
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are based on the areliminary information available and are only an estimate. Contact the Deot for addn'l info.
]FEE ITEMS (Tee Resolution 11 -053 Eff.' 7i1/13
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
0 # Tenant Improvement Prep
$417.00 ITIPREP
Suppl. PC Fee: Q Reg. 0 OT
Q.Q
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. OT
Q Q
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
J.ri:llr!•Ir,rlr,t ,'�'c
0
E)
Work Without Permit? 0 Yes E) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non - Residential
Building or Structure
d
Strom Motion Fee: IBSEISMICO
$0.56
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$1.56
$417.00
TOTAL FEE:
$418.56
Revised: 10101/2014